PAC 320 Module 3 Assessment Tools Example

Two Admissions, One Morning: Withdrawal Scales, Motivation and Multidimensional Placement at a Treatment Center

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 320: Psychology of Addiction

Instructor Name

Month Day, Year

Two Admissions, One Morning: Withdrawal Scales, Motivation and Multidimensional Placement at a Treatment Center

On a Monday morning, two people arrived at Cedar Hill Recovery Center, the invented Asheville program in these papers. Wayne, fifty-eight, a retired machinist, had been drinking about a fifth of vodka a day for two years since his wife's death; his last drink was twelve hours earlier, and his hands were shaking. Brittany, twenty-six, a restaurant server, had been using fentanyl daily for a year; her last use was eighteen hours earlier, and she was sweating, yawning and restless. Both needed to be assessed quickly and accurately. This paper reviews the tools Cedar Hill uses at admission and applies them to both clients. Wayne, Brittany and Cedar Hill are invented composites; the tools and research are real.

Measuring Alcohol Withdrawal

Alcohol withdrawal can be dangerous, progressing in some people to seizures or delirium. Sullivan et al. (1989) revised an earlier alcohol withdrawal instrument into the Clinical Institute Withdrawal Assessment for Alcohol, revised, or CIWA-Ar. A clinician rates ten signs, ranging from nausea, shaking and sweats through restlessness, worry and disturbed touch, hearing or vision to headache and how well the person knows where and when they are. Most items are rated from zero to seven, and orientation from zero to four, for a maximum score of sixty-seven. The authors found good interrater reliability, and the scale became widely used to guide symptom-triggered medication, in which medication is given when scores reach a threshold rather than on a fixed schedule. Scores below about ten generally indicate mild withdrawal.

Wayne scored fourteen, with moderate tremor, sweating and anxiety. His history adds risk: he reported a withdrawal seizure three years ago.

Measuring Opioid Withdrawal

Opioid withdrawal is rarely dangerous in itself but is intensely uncomfortable and drives people back to use. Wesson and Ling (2003) described the Clinical Opiate Withdrawal Scale, or COWS, an eleven-item clinician-rated scale. It covers resting pulse, sweating, restlessness, pupil size, bone or joint aches, runny nose or tearing, gastrointestinal upset, tremor, yawning, anxiety or irritability and gooseflesh. Scores are grouped into mild, moderate, moderately severe and severe withdrawal. The scale is commonly used to decide when to begin buprenorphine, which can precipitate sudden withdrawal if started too soon after a full opioid such as fentanyl.

Brittany scored fifteen, in the moderate range, high enough for Cedar Hill's prescriber to consider starting buprenorphine.

Measuring Readiness

Miller and Tonigan (1996) developed the Stages of Change Readiness and Treatment Eagerness Scale, known as SOCRATES, to measure drinkers' motivation for change. Analysis of the items produced three scales: Recognition, the degree to which a person acknowledges a problem; Ambivalence, uncertainty about whether there is a problem; and Taking Steps, the degree to which a person is already acting to change. The scales showed good reliability. A version for drug use was also developed.

Wayne scored high on Recognition and Taking Steps; he said he knew his drinking was killing him. Brittany scored high on Recognition and moderately on Ambivalence; she wanted to stop fentanyl but feared being sick and losing her apartment if she went to residential care.

The ASAM Criteria

Mee-Lee et al. (2013) set out the ASAM criteria, the most widely used framework in the United States for matching people with substance use disorders to levels of care. The criteria assess six dimensions: acute intoxication and withdrawal potential; biomedical conditions and complications; emotional, behavioral or cognitive conditions; readiness to change; relapse, continued use or continued problem potential; and recovery environment. Levels of care range from early intervention through outpatient, intensive outpatient and partial hospitalization to residential and medically managed inpatient services. The guiding principle is that placement depends on the person's needs across all six dimensions, not on the substance or on a fixed program length.

Applying the Six Dimensions

What the Tools Did Not Capture

The instruments measured withdrawal and readiness well, but the interviews supplied information no scale captured. Wayne's grief for his wife, two years after her death, emerged when the counselor asked when his drinking had changed, and it explained both his drinking and his depressed mood better than any score. Brittany's fear of losing her apartment, which shaped her ambivalence about residential care, came from a question about what worried her most about treatment. The ASAM framework asks about these matters in dimensions three and six, but it depends on a counselor who listens. The tools organize the assessment; the conversation fills it in.

The Placements

Wayne's withdrawal risk, his seizure history and his living alone point to medically monitored residential withdrawal management, followed by Cedar Hill's residential program and then outpatient care. Brittany's withdrawal can be managed with buprenorphine, her environment is supportive and her ambivalence about residential care is itself a reason not to force it. She will start buprenorphine under the prescriber's supervision and enter intensive outpatient care, three hours a day, four days a week, keeping her apartment and her job.

Assessment Continues

Assessment does not end at admission. Wayne's CIWA-Ar will be repeated every few hours during withdrawal, guiding medication, and his mood will be reassessed once withdrawal resolves, since grief and depression may need their own treatment. Brittany's COWS will guide her buprenorphine induction, and her placement will be reviewed weekly; if she returns to fentanyl, a higher level of care will be reconsidered with her. SOCRATES will be repeated at thirty days for both.

Conclusion

Two clients arrived the same morning with different substances, risks and lives. Sullivan and colleagues' CIWA-Ar and Wesson and Ling's COWS measured their withdrawal, Miller and Tonigan's SOCRATES described their readiness and the ASAM criteria integrated these findings across six dimensions into two different placements. The tools work together, and their value lies in the decisions they make possible and in the reassessment that follows.

References

Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Miller, M. M. (Eds.). (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions (3rd ed.). The Change Companies.

Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10(2), 81-89. https://doi.org/10.1037/0893-164X.10.2.81

Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x

Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs, 35(2), 253-259. https://doi.org/10.1080/02791072.2003.10400007